Hospitals innovate to cut ER logjams

Bob Groves, McClatchy/Tribune NewsCHICAGO TRIBUNE

The waiting room in the emergency department at Palisades Medical Center has a magnificent view of the Manhattan skyline. But patients had better look fast: The hospital says its ER wait time is down to nine minutes.

Walk-in patients used to wait an hour or more before they were examined by a nurse at the North Bergen, N.J., hospital's ER. Then they waited again to see a doctor.

But that was before Palisades reorganized the front end of its emergency department into a rapid evaluation unit. Now, a team of two nurses, a technician and a physician move two or three patients at a time through fast-track triage and treatment.

Sixty percent of these patients are treated by this team -- freeing the main emergency department to care for the most serious cases.

"Treat and release is the key," said Gladys M. Sillero, a nurse and clinical coordinator of the emergency department, which logs 36,500 visits a year.

Time is a constant struggle at hospital emergency rooms, which are increasingly overwhelmed by growing numbers of unemployed and uninsured people who need care.

Nationwide, wait times average 37 minutes -- more than twice the recommended time frame for the most critical patients, according to the federal Government Accountability Office. And that's just the time it takes to have someone ask what's wrong and check your vital signs.

Door-to-treatment-to-discharge averages 4 hours 3 minutes, according to an analysis of 1,725 emergency rooms by Press Ganey, a consultant for more than 40 percent of hospitals in the U.S.

Long waits for care are "very troubling and dangerous," said Dr. Nick Jouriles, president of the American College of Emergency Physicians.

Emergency room gridlock is most often blamed on the lack of beds for ER patients who need to be admitted to the hospital, Jouriles said. Patients waiting for those beds are often "boarded" in the ER, where they must be monitored and take up the time of physicians and nurses there.

"No matter how fast I move, I can have people sitting in the ER waiting 12 to 25 hours" for a bed in the hospital, he said.

To solve its "really significant problem" of patient boarding, St. Joseph's Regional Medical Center in Paterson, N.J., installed an electronic bed-tracking system so the staff knows when beds open up, said Dr. Mark Rosenberg, chairman of emergency medicine.

A bed is usually available now within six hours, but "you always have bad days when things don't move," he said.

At St. Joseph's, the door-to-doctor average time for non-acute patients is 24 minutes.

"We're one of the largest emergency departments in the state, but we've taken many steps to streamline the care," said Rosenberg, whose ER treats 130,000 cases a year. "You can wait longer in your doctor's office than in an acute-care center."

The wait-time numbers in this story were reported by the hospitals themselves.

The financially beleaguered St. Mary's Hospital in Passaic, N.J., has set an aggressive goal for its ER: Door-to-discharge in 60 minutes under a new prompt care unit, said Vanessa Warner, a spokeswoman. Currently, the door-to-discharge time is 2 hours 44 minutes.

Englewood (N.J.) Hospital and Medical Center is also speeding up service. Walk-in patients are immediately triaged by a nurse and see a doctor within 25 minutes, said Dr. David J. Istvan, chief of emergency medicine. When the expanded ER opens soon, it will have its own radiology department and bedside ultrasound to help physicians diagnose injuries and illnesses more quickly. The ER will also have more beds -- 40 instead of the current 25 -- to handle the increasing numbers of patients who walk in.

Holy Name Hospital in Teaneck, N.J., changed to a quicker triage process in 2008, said Joseph Giles, a nurse and administrative director of critical-care emergency services. After a patient registers, a triage nurse reviews his complaints and vital signs and assigns an emergency severity index score, Giles said. Average door-to-triage time is 12 minutes.

Reorganizing an emergency room for rapid patient evaluation requires "a cultural change," said Gerardi of Morristown Memorial. Sometimes the "two guilty parties" resisting such change, he said, are physicians, who are too busy treating patients, and nurses, who feel their system is already well-organized.